EURURO Vol. 72 No. 3

343 476

Platinum Priority – Editorial
Referring to the article published on pp. 333–342 of this issue
Je le pansai, Dieu le guerit
Akshay Sood Firas Abdollah, Mani Menon
Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
I think about this editorial as I walk [2_TD$DIFF]by the Hotel-Dieu in
Paris. I reflect upon the words of Ambroise Pare´ , a surgeon to
kings and commoners, ‘‘Je le pansai, Dieu le guerit’’—‘‘I
dressed the wound, God healed it.’’ Is this not what happens
with erectile function after radical prostatectomy?
In this month’s issue of European Urology, Villers et al
boldly explore the idea of a partial prostatectomy as a
treatment option for focal prostate cancer in an effort to
improve potency after prostatectomy.
A radical prostatectomy is a good operation with a bad
reputation. In the early 2000s, opinions about open radical
prostatectomy were ambivalent: its advocates celebrated
a 99% cancer control rate, while the skeptics worried over a
1200-cc blood loss, and 20% incontinence, 15% stricture,
and 60–95% erectile dysfunction rates [3_TD$DIFF] . Minimally
invasive prostatectomy changed much of this—the blood
loss dropped to approximately 100 cc, and the inconti-
nence and stricture rates today are around 1–2% [4_TD$DIFF] . Yet,
potency rates have remained stubbornly recalcitrant to the
technical refinements, and approximately 50% of men
continue to suffer from major erectile dysfunction at
12 mo following a bilateral nerve-sparing robotic prosta-
tectomy [5_TD$DIFF] .
Why is [6_TD$DIFF]this – that if you preserve the nerves you can
restore continence but not erectile function? A clue may lie
in the results from the treatment of benign prostatic
disease. Erectile dysfunction rates are astonishingly low
after a transurethral resection of the prostate or a
suprapubic prostatectomy—operations in which the surgi-
cal capsule of the prostate is preserved [7_TD$DIFF] Potency rates are
similarly high after prostate-sparing cystectomy [8_TD$DIFF] And
they are high with focal prostate ablation [9_TD$DIFF] . Thus it
appears that the key to preserving potency may lie in
developing techniques that preserve the prostatic capsule.
In order to justify and endorse such an approach, we
must change the way we think of prostate cancer. Yes, some
patients have advanced cancer, but others do not. Indeed,
the death rate in patients with prostate cancer who
were monitored with active surveillance in the recently
completed ProtecT trial was only 1.5 events at 1000 yr of
follow-up [10_TD$DIFF] Perhaps, the management of prostate
cancer in these patients can follow the organ-preservation
approach taken in themanagement of almost all other solid
organ tumors, as argued eloquently by Ahmed[11_TD$DIFF] et al [12_TD$DIFF]
[13_TD$DIFF]They reported on the use of focal high-intensity focused
ultrasound for the treatment of prostate cancer, treating
just the lesion and staying 1 cm away from the
contralateral capsule [9_TD$DIFF] In a select group of 41 men,
they noted an 89% potency rate at 12 mo, and a 100%
continence rate immediately. However, 23% of the men
experienced a recurrence with 10% requiring further
treatment by 6 mo.
In the present study, Villers et al describe a novel,
nonablative technique of focal therapy—the partial prosta-
tectomy. Men with preurethral, low-to-intermediate risk
anterior prostate cancers diagnosed using magnetic reso-
nance imaging were included. Figure 6 shows the key
results . Briefly, in a carefully screened group of 17 men,
partial prostatectomy led to preserved erectile function in
83% and preserved continence in 100% of the men. Similar to
the series by Ahmed [12_TD$DIFF] , however, 24% of the patients
developed recurrence and required completion radical
prostatectomy, with an immediate loss of erectile function.
These results are controversial. Many patients and their
surgeons will not accept a one in four recurrence rate to
achieve an 80–90% potency rate. But some may. After
all, variations of this argument were raised when Walsh
first proposed nerve-sparing techniques (often dubbed
ava ilable at
journal homepage:
DOI of original article: .
* Corresponding author. Vattikuti Urology Institute, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA. Tel.+1-443-691-3193;
Fax: +1-313-916-4352.
E-mail address: (A. Sood).
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.